Basic Information
| Provider Information | |||||||||
| NPI: | 1538743752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMESURGE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 496084 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302410473 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 GRAND AVE STE K | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917654172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098604254 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2021 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | ABAZA | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8187268722 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.